What Happens When Medicare Stops Paying for Nursing Home Care?

Medicare is a lifeline for many people who experience a health need, such as an illness that requires rehabilitation in a treatment facility. Yet, there are limits to when and how Medicare covers care, such as in a nursing home stay. It is critical not only to understand when Medicare runs out but also to know your options after it happens, especially when you still need more help.

Does Medicare Pay for Nursing Home Care?

Medicare provides financial support for skilled nursing facility care, a specific type of nursing home care that incorporates medical support from registered nurses and physical therapists. This type of professional care is usually a form of rehabilitation that becomes necessary after leaving a hospital setting.

To obtain Medicare coverage for skilled nursing, most people will need to have spent at least 3 days in a hospital, which is considered a qualifying hospital stay. This skilled nursing care falls under Medicare Part A, a part of Original Medicare. It will cover up to 100 days of skilled nursing facility care during any benefit period. However, it does so at different rates:

• Medicare pays all of the costs for the first 20 days.
• From Day 21 to Day 100, patients pay a daily coinsurance amount.

This skilled nursing care is only for short-term, non-custodial care. Custodial care, by contrast, refers to care that is necessary on an ongoing basis for activities of daily living, including eating, bathing, and dressing. Custodial care is more commonly associated with the type of support received in a nursing home. Medicare doesn’t cover custodial care if it’s the only care you need. Remember that Medicare coverage for nursing care depends on a qualifying hospital stay during the benefit period. This is one of the many factors to consider when it comes to understanding Medicare coverage.

So, what happens when Medicare stops paying for nursing home care? To clarify, Medicare does not pay for nursing home care but does cover the cost of skilled nursing care, as noted above.

In all cases, you may be wondering what happens once medicare benefits are no longer available for the care necessary. Your Medicare benefits may no longer apply, but there are other strategies that may be able to help you cover the costs of the skilled nursing services or nursing home care you need.

Medicaid Eligibility

Some people who have met the cap on skilled nursing services required by Medicare may qualify for Medicaid, a state-run program that helps to cover the financial costs of medical care for people who may not be able to cover those costs themselves.

Medicaid, for those who qualify, will cover the cost of a nursing home. However, for this to occur, you must meet income and asset criteria, which differ from one state to the next. Those who own assets like a home may not qualify for Medicaid.

If you qualify, Medicaid will cover the cost of necessary nursing home care on an ongoing basis. There are solutions for those who may not seem to qualify, and you should reach out for help in these areas.

Veterans Benefits

For qualifying individuals, Veterans’ benefits could be a tool to help cover some of the care costs. Veterans and their dependents may be able to gain some support when Medicare coverage for skilled nursing facilities runs out. The Department of Veterans Affairs offers programs that may cover some or all of the costs associated with your long-term care needs. That includes nursing home care.

However, to qualify, you must meet the eligibility requirements for Veterans’ benefits. This is based on disability status, military service history, and financial need. One of the specific tools that may help you is the Aid and Attendance benefit, which provides financial assistance to those who require the aid of another person or those who are housebound. To learn if you have this type of support, including income and asset requirements, contact your VA health care office for more insight.

Using Long-Term Care Insurance

For those who purchased long-term care insurance at a previous time in their life, that insurance could help to cover their nursing home costs now. This type of coverage may help provide you with coverage for nursing home costs as well as other expenses that Medicare does not.

If you did not purchase this type of insurance early on, it may not be available to you. Many of these insurance plans also have specific requirements based on the type of inpatient hospital care you receive, whether you need memory care, or other limitations on the type of nursing facility you go to.

Medicare Advantage Plans

Medicare Advantage Plans, sometimes referred to as Medicare Part C, are private health insurance plans that contract through Medicare. If you do not have Original Medicare but opted for an Advantage Plan, coverage for nursing home care may be available to you. Not all Medicare Advantage Plans will offer the same skilled nursing services, either. Some may offer more or less.

Medigap Coverage

Another avenue of consideration is Medigap insurance. Medigap is an optional private insurance plan that some obtain while enrolling in Original Medicare. It helps cover gaps in financial protection or costs that Medicare does not cover. Regarding nursing home care, Medigap may offer little or some coverage. Policies differ significantly in the type of out-of-pocket costs they cover.

Notably, some policies will pay for a patient’s coinsurance for that block of time between care levels (days 21 to 100). You’ll need to refer to your policy for specific insights. This is a good factor to consider when comparing available plans as well.

Private Pay

If you need to continue receiving support in a skilled nursing facility or nursing home, you may be able to pay for these costs out of pocket. The costs vary widely based on location but typically range between $250 and $600 daily. Covering nursing home care like this can be financially challenging for many people, especially if they have income and asset limits.

Planning for Nursing Home Expenses

Many people need financial assistance to cover the cost of nursing homes. Since Medicare and nursing homes do not go hand-in-hand, it helps to put in place a plan that could help you navigate the financial implications.

For example, by taking a proactive approach to planning for your potential nursing home expenses, in-home care needs, or other continued care needs as you get older now, you may be able to meet the qualifications for Medicaid coverage. Consider some of the opportunities that may help you achieve this goal.

When Medicare coverage ends for any of your health needs, having a plan in place to ensure you can continue to receive the necessary support for your health and well-being is critical. Consider several of the steps that could help you reach that point.

Medicaid Spend Down

Medicaid planning, a component of elder law provided by various estate planning attorneys and services, aims to help people qualify for Medicaid. The Medicaid Spend Down process requires that you spend down your assets so you meet Medicaid eligibility requirements by the time you need it.

This process typically requires you to reduce your assets, such as stocks, bonds, investment accounts, bank accounts, and other countable investments. Your objective is to reduce your assets to Medicaid limits. In some situations, Medicaid will exempt specific assets, such as your home, vehicle, and personal belongings (rules differ from one state to the next).

This type of plan provides more financial stability because you can plan for your need for ongoing care, and when the time comes to receive it, you can obtain it without worrying as much about nursing home care costs.

Privately Paying for Care

Medicaid may not be available to everyone, and as a result, you may need to pay out of pocket for the care you need now. That could mean using your savings account or selling off assets to help you meet the financial needs necessary. To do this, you are often required to consider the liquidity of your assets and calculate the monthly nursing home costs.

The problem with this method is that most people need ongoing care, and the longer you need it, the faster your savings drain. Nursing home care could become even more expensive if you desire additional services, like a private room.

Community and In-Home Alternatives

For some people, neither of these options seems desirable. You may want to look for alternatives that could allow you to reduce the costs of ongoing care. For example, community services, as well as in-home care services, may be an alternative to nursing home care and skilled nursing services.

If you are living with family members but need support during the day when they are at work, you may want to consider adult daycare options. These programs may fill in the gaps of care when you have people to support you at most times of the day and night.

Alternatively, you may not need full-time support at all. Some people can benefit from using in-home care. This might include having home health services come to your home to provide you with the services you need, including assistance with daily living skills. You will still need to use financial resources for this process, but it may be more desirable for those who want to stay at home.

Another option to consider is assisted living communities. These communities allow you to move into a location that will provide you with the support you need, such as help with cooking and cleaning. You live within an area, but you still maintain some privacy (often with a private room or suite). 

Putting a Plan In Place for Nursing Home Care

As you consider all of these factors, think about what your options are. When possible, start planning for your needs now. Here’s what to expect.

• A qualifying inpatient hospital stay occurs. Medicare hospital insurance, or Medicare Part A, covers those costs. You are in the hospital for at least three days. You are able to recover, but you are not ready to go back home because of injuries or the need for rehabilitation and physical therapy.
• You may be able to move into skilled nursing home care. For the first 20 days, Medicare will pay the full cost of your professional nursing home care as long as it is a required service and the location is Medicare-approved.
• From days 21-100, you begin paying coinsurance or a portion of the cost to remain in a skilled location and receive care from certified nursing assistants. You can use private funds to cover these costs or Medigap coverage if you purchased it.
• On Day 101, you have to make a decision on the care you need. If Medicare coverage ends prior to you reaching a level of being able to go home, you may have to apply for Medicaid, use long-term care insurance you previously purchased, or use your personal savings.

What to Do Now As You Plan for the Future

As you are looking into the future with an eye for planning for potential care needs, working with an elder law attorney or a service that can help you create a cohesive plan is critical before a hospital-related medical condition occurs, and you don’t have the necessary steps in place.

As you get older, you may be thinking about the benefits of moving into a senior living community where you can have better access to the support you need, should you need it over time. You may be ready to consider assisted living communities that can offer the type and level of support you need, like medication management and human services in the home.

One of the most important factors to know is that you are not alone. CarePatrol can help you find the right care option for your care needs. In addition to assisted living, memory care, and independent living options, we also guide families in exploring in-home care services, which allow older adults to enjoy the comfort and familiarity of their own homes while receiving personal care and support.

Medicare covers a wide range of services, but it does not provide ongoing support. Covering nursing home care and continued care is something very different. As you work towards recovery or help your loved one navigate what happens when Medicare coverage for nursing support ends, know that CarePatrol is available to guide and support you. Reach out to us for a comprehensive evaluation and support right now.